STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONSDepartment of Human ServicesOFFICE OF CHILD SUPPORT SERVICES77 Dorrance Street

Providence, RI 02903 (401) 458-4400/www.cse.state.ri.us

Dear Applicant,

Enclosed is the application for child support services that you recently asked for from this office. To help us process your application as quickly as possible, please return the application to the above address along with the following information.

• The application filled out to the best of your ability• Form DR6A Statement of Assets, Liabilities, Income and Expenses filled out, signed by you.

(Note: your signature must be notarized)• a copy of each child’s birth certificate• a copy of your divorce decree; if you have one• a $20.00 personal check or money order application fee made out to:

Office of Child Support Services • Signed waiver regarding legal representation • Child Support Payment Notice• Family Violence Indicator form (only if applicable)

If you are worried about a domestic violence issue and believe that you are in need of having your address and certain personal information protected from the non-custodial parent, please fill out SECTION TWO of the Family Violence Status Form enclosed with this application. If you believe that there is personal information in your COURT FILE that should also be protected, fill out SECTION TWO AND SECTION THREE of the Family Violence Status Form.

You have a RESPONSIBILITY to provide Social Security numbers for yourself and your household on your application. Your Social Security number, as well as the Social Security numbers of all members of your household will be used in computer matching with the Department of Labor and Training, the Social Security Administration, the Internal Revenue Service, and other governmental and non-governmental entities authorized by law, regulation or contract and they will be subject to verification by Federal, State and local officials.

Once your completed application is received, a child support agent will review your case to determine if any further information is needed. You may be contacted in writing, or by phone, to provide additional information. Our goal is to assist you in obtaining child support for your children.

Rev. 07/08STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONSDepartment of Human ServicesOFFICE OF CHILD SUPPORT SERVICES77 Dorrance Street

Providence, RI 02903 (401) 458-4400/www.cse.state.ri.us

Application for Child Support Services

Important information about the NON-CUSTODIAL PARENT (NCP) Información importante del padre/madre sin la custodia (NCP)

Social Security Number(Numero de Seguro Social)______________________________________________________________

Name (Nombre)__________________________________________________________________________________________ Last First Middle Sr., Jr., III, etc., Date of Birth (Fecha de Nascimiento):______________________ Sex (Sexo): Male Female

Ethnic Background (Origen étnico): ______________________________________________ (White, Black, Hispanic, Asian, etc.)

Important information about YOU, the CUSTODIAL PARENT (CP)Información importante de USTED, el padre/madre con la custodia (CP)

Social Security Number(Numero de Seguro Social)______________________________________________________________

Name (Nombre)__________________________________________________________________________________________ Last First Middle Sr., Jr., III, etc., Date of Birth (Fecha de Nascimiento):______________________ Sex (Sexo): Male Female

Ethnic Background (Origen étnico): ______________________________________________ (White, Black, Hispanic, Asian, etc.)

PROTECT ADDRESS (DOMESTIC VIOLENCE) Proteger Dirección por (VIOLENCIA DOMESTICA)

Protect address due to domestic violence? (Necesita proteger su dirección?) Yes (Si) No Whose address? La dirección de quién? NCP CP

NON-CUSTODIAL PARENT address information (NCP) Direccion del padre/madre sin la custodia (NCP)

Residence/Home Address(Residencia/Dirección de la vivienda) :_______________________________________________________

Number Street ________________________________________________________________________________________________________ City State Zip Code

Mailing address (if different from above): ____________________________________________________________________ Donde recibe correo si diferente a la de arriba:

Who is the NCP living with?(Con quien vive el NCP?)_______________________________________________________________

NCP Telephone (telefono) home(casa): ___________________ work (trabajo):

____________________other(otro)_______________

FOR OFFICE USE ONLY(PARA USO DE OFICINA SOLAMENTE)Application requested: _____/______/______ Mailed: _____/____/_____ Received:____/____/____Are you and the Non-custodial parent currently married? YES NO (Está usted y el padre/madre sin custodia actualmente casados?)

Were you and the Non-Custodial parent ever married? YES NO (Estuvieron casados usted y el padre/madre sin custodia?)

Are you and the Non-Custodial parent divorced? YES NO (Estan usted y el padre/madre sin custodia divorciados?)

Date of Divorce ____________________ Divorce Number________________ Location___________________ Fecha del Divorcio Numero del Divorcio Lugar

Is the NCP employed? Check one: Full-time Part-time Temporary Unemployed Está el padre/madre sin custodia trabajando? Place of Employment (Lugar de Empleo):___________________________________________________________________ Employer Address:________________________________________________________________________________________Dirección Street City State Zip code Employer Phone Number:___________________________________________________________________________ Telefono del empleador Physical Description: Height(Altura)__________ Weight(Peso)__________ Complexion(Tono)___________________Descripción Fisica Eye Color_______________ Hair Color________________ Race_______________________ Color de Ojos Color del Cabello Raza Physical Markings/ Scars (Marcas Fisicas/ Cicatricez)________________________________________________________ Wears Eye glasses (Usa lentes)? YES NO U.S. Citizen (Ciudadano Estaunidense)? YES NO Nicknames/Alias:____________________________________ Otros nombres usados/sobrenombres?

Driver’s License:_____________State of ___________________________ License Number:______________________Licencia de Manejar Stado de: Numero de Licencia

Does NCP own a motor vehicle(Tiene el NCP carro?) YES NO If yes, describe below: (Describalo)

____________ _______________ ___________ ____________ _____________________________

NON-CUSTODIAL PARENT employment & physical description information (NCP)Información de trabajo y fisica del PADRE/MADRE SIN LA CUSTODIA (NCP)

Year Make Model Color License Plate # / State Año Marca Modelo Color Numero de Placas / Stado

Are you and/or the children currently covered by medical insurance? YES NO Tienen seguro medico usted y sus hijos?

Medical coverage is provided by: Custodial parent Non-Custodial parent Other Cobertura medica proveida por: Padre/madre con custodia Padre/madre sin la custodia Otro

Medical Insurance Policy Number: ______________________________________________________________________Numero de Poliza del Seguro Medico

Medical Insurance Company _____________________________________ Type of coverage ____________________Compania de Seguro Medico Tipo de CoberturaYour Address (Su Dirección):_________________________________________________________________________________

________________________________________________________________________________________ City (Ciudad) State (Estado) Zip Code (Codigo Postal)

Your Mailing Address (if different from above): ___________________________________________________________Donde recibe correo si diferente a la de arriba: _____________________________________________________________________________ City (Ciudad) State (Estado) Zip Code (Codigo Postal)

Your Telephone Number (Numero de Telefono) Home(casa):_________________ Work(Trabajo):_______________________

Cell(Celular):_________________________ Other(Otro):__________________________________________________________

U.S. Citizen? YES NO What is your relationship to the non-custodial parent? Ciudadano Estaunidense? Cual es su relación con el padre/madre sin la custodia?

Married Separated Divorced Never Married Legally Separated Loco Parentis Casados Separados Divorciados Nunca Casados Legalmente Separados

Your Place of Employment: _______________________________________________________________________________Donde Trabaja usted:

Employer Address:___________________________________________________________________________________________ Dirección de su empleador: HAVE YOU EVER RECEIVED ASSISTANCE IN ANOTHER STATE? YES___ NO___A recibido usted ayuda publica en otro estado?IF YES, NAME OF STATE____________________________________

El nombre del otro Estado:Please enclose copy of birth certificate for each child. Por favor enviar copias del Certificado de Nascimiento de cada niño.

MEDICAL COVERAGE Information (Información de COBERTURA MEDICA)

CUSTODIAL PARENT information (CP) Información del PADRE/ MADRE CON LA CUSTODIA(CP)

CHILDREN information (List only the children of the NCP named in this application)Información de los Niños (Ponga solo los hijos/as del NCP que nombro en esta aplicación)

Child #1. Name (Nombre):____________________________________________________________________________________Niño #1 Last First Middle Jr., Sr., III, etc.

Social Security Number: _______________________________________________ Sex (Sexo) : Female Male Numero de Seguro Social: Date of Birth: ________________________ Birthplace: ______________________________________________________ Fecha de Nascimiento: Lugar City State Ethnic Background (Origen étnico): _______________________________________ US Citizen? YES NO

Does the Non-Custodial Parent’s name appear on the birth certificate? YES NO Aparece el nombre del padre sin la custodia en el certificado de nascimiento?

Has paternity ever been established through the court for this child? YES NO A sido establecida la paternidad para este niño/a a travez de una corte ? If yes, court location(lugar de la corte):________________________________________ Date (Fecha):__________________

Is there a court order for support for this child? YES NO Hay una orden de Manutención para este niño/a? If yes, amount of support ordered (cantidad de la orden) $____________________ Frequency (Frecuencia):____________________

Date of

order: _____________________ Court Docket No. _________________ Court Location: _________________Fecha de la orden: Numero de la orden: Lugar donde se ordeno la orden

Child #2. Name(Nombre)_______________________________________________________________________________ Last First Middle Jr., Sr., III, etc.

Social Security Number: _______________________________________________ Sex (Sexo) : Female Male Numero de Seguro Social:

Date of Birth: ________________________ Birthplace: ______________________________________________________ Fecha de Nascimiento: Lugar City State

Ethnic Background (Origen étnico): _____________________________ US Citizen? YES NO

Does the Non-Custodial Parent’s name appear on the birth certificate? YES NO Aparece el nombre del padre sin la custodia en el certificado de nascimiento?

Has paternity ever been established through the court for this child? YES NO A sido establecida la paternidad para este niño/a a travez de una corte ? If yes, court location(lugar de la corte):________________________________________ Date (Fecha):__________________

Is there a court order for support for this child? YES NO Hay una orden de Manutención para este niño/a? If yes, amount of support ordered (cantidad de la orden) $____________________ Frequency (Frecuencia):____________________

Date of order: _____________________ Court Docket No. _________________ Court Location: _________________Fecha de la orden: Numero de la orden: Lugar donde se ordeno la orden

CHILDREN information (List only the children of the NCP named in this application)Información de los Niños (Ponga solo los hijos/as del NCP que nombro en esta aplicación)

Child #3. Name(Nombre)_______________________________________________________________________________ Last First Middle Jr., Sr., III, etc.

Social Security Number: _______________________________________________ Sex (Sexo) : Female Male Numero de Seguro Social:

Date of Birth: ________________________ Birthplace: ______________________________________________________ Fecha de Nascimiento: Lugar City State

Ethnic Background (Origen étnico): _______________________________________ US Citizen? YES NO

Does the Non-Custodial Parent’s name appear on the birth certificate? YES NO Aparece el nombre del padre sin la custodia en el certificado de nascimiento?

Has paternity ever been established through the court for this child? YES NO A sido establecida la paternidad para este niño/a a travez de una corte ? If yes, court location(lugar de la corte):________________________________________ Date (Fecha):__________________

Is there a court order for support for this child? YES NO Hay una orden de Manutención para este niño/a? If yes, amount of support ordered (cantidad de la orden) $____________________ Frequency (Frecuencia):____________________

Date of order: _____________________ Court Docket No. _________________ Court Location: _________________Fecha de la orden: Numero de la orden: Lugar donde se ordeno la orden

IF MORE THAN 3 CHILDREN, ATTACH ADDITIONAL INFORMATION ON A SEPARATE SHEET OR MAKE A COPY OF THIS PAGE. (Si tiene más de 3 niños, escriba la información en otra hoja o haga una copia de esta pagina)

____________________________________________ _____________________Applicant’s Signature (Firma del Aplicante) Date(Fecha)

STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONSDepartment of Human ServicesOFFICE OF CHILD SUPPORT SERVICES77 Dorrance Street

Providence, RI 02903 (401) 458-4400/www.cse.state.ri.us

NOTICE AND WAIVER REGARDING LEGAL REPRESENTATION

I understand that the Department of Human Services – Office of Child Support Services attorneys are not my attorneys and do not represent me, even though I may benefit from the work of those attorneys. I understand that the only client of the Department of Human Services – Office of Child Support Services is the State of Rhode Island. Because I do not have an attorney / client relationship, it means that any information I share with the Department of Human Services – Office of Child Support Services or their attorneys is not privileged or confidential, except as otherwise provided by law. It also means that the Department of Human Services – Office of Child Support Services may provide services to the other parent of my child or another person, agency or department having custody / physical possession of my child and in need of the agency’s services.

(Yo entiendo que los abogados del Departamento de Servicios Humanos, Oficina de Servicios para el Sustento de Menores, no son mis abogados y no me representan a mi, aunque yo me beneficie del trabajohecho por estos abogados. Yo entiendo que el unico cliente del Departamento de Servicios Humanos, Oficina de Servicios para el Sustento de Menores es el estado de Rhode Island. Por lo que yo no tengo una relación de cliente/abogado, cualquier información que yo de al Departamento de Servicios Humanos, Oficina de Servicios para el Sustento de Menores no es privilegiada o confidencial, excepto como es proveido por la ley. Tambien significa que el Departamento de Servicios Humanos, Oficina de Servicios para el Sustento de Menores puede proveer servicios al otro padre/madre de mi hijo/a o a cualquier otra persona, agencia, departamento que tenga la custodia o posesión fisica de mi hijo/a y que necesite los servicios de esta agencia.

Please Print your name:_________________________________________________Escriba su nombre:

Signature:____________________________________________________________Su firma:

Your Social Security Number:____________________________________________Su numero de Seguro Social

Please return with your application – Por favor devuelva junto con su aplicación.

STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONSDepartment of Human ServicesOFFICE OF CHILD SUPPORT SERVICES77 Dorrance Street

Providence, RI 02903 (401) 458-4400/www.cse.state.ri.us

FAMILY VIOLENCE QUESTIONNAIRE

YOUR NAME: _____________________________ Your Social Security # _______-____-_________

OTHER PARTY’S NAME: __________________________________ Case# ___________________*************************************************************************************SECTION ONE: SAFETY ISSUES - Please answer each question

YES or NO Have you or a child care ever been a victim of domestic violence or child abuse committed by the other party in your child support case? YES or NO Have you ever obtained a restraining order, emergency protective order or no contact order against the other party to your child support case? In what county/state: __________________ Court Case Number: __________ Is the order still in effect? No_____ Yes______, until ___________________(date) YES or NO Does the other party know your address?

*************************************************************************************SECTION TWO: At this time are you in fear of the other party for your safety or your child(ren)‘s safety? YES or NO

A. IF YOU ANSWERED NO TO THIS QUESTION, please read the following statement and sign your name and date. (Do not complete Section Three on the back of this page; simply return this form to your child support agent,)

The disclosure of my address or other information identifying my location is not harmful to me or the child(ren) in my care. I understand this information will be made available to the federal government, courts, child support agencies and sometimes to the other parent of the child(ren).

Date: _____________ _______________________________________________________________ Name

B. IF YOU ANSWERED YES TO THIS QUESTION, please read, date and sign the following statement. OCSS will not share your address information on the OCSS computer system with the other courts, child support agencies, or the other parent without a court order. After signing below, complete SECTION THREE on the back of this page.

The disclosure of my address or other information identifying my location could be harmful to me or the child(ren) in my care. I am requesting that my address or other identifying information not be given to the other party in this case. This request for non-disclosure of information can be removed if I notify the local child support agency in writing, and the office that manages my case acknowledges that they have received my request. This request for non-disclosure will be reviewed periodically by OCSS and I understand that may be required to renew my request. I understand that under federal law, an authorized person may submit a written request to the court which has jurisdiction to make or enforce child custody or visitation determinations. I will be notified in writing by the local child support agency if the court orders the release of information on my case.

Date: __________________ Name: ___________________________________________________SECTION THREE: SEALING THE COURT FILE DUE TO FAMILY VIOLENCE

ANSWER #1 OR #2 BELOW ONLY if you answered “YES” to the question in SECTION TWO “B”: (Please read the following information carefully)

1.. IF YOU WANT YOUR ADDRESS PROTECTED IN THE COURT FILE, OCSS WILL FILE A MOTION TO SEAL THE COURT FILE **

That Motion is served on the other party and he/she will have the right to come to court to object to the file being sealed. You may have to testify in a Court hearing on whether the file should be sealed permanently to protect your information.

** NOTE: IF YOUR CASE IS BEING SENT TO ANOTHER STATE FOR ESTABLISHMENT OR ENFORCEMENT, THE LAWS AND PROCEDURES OF THE OTHER STATE WILL DETERMINE WHETHER THE COURT FILE IS TO BE SEALED BY THAT STATE.

2. IF YOU DO NOT WANT YOUR ADDRESS PROTECTED IN THE COURT FILE OCSS will still protect your information on the OCSS computer system, but will not ask the Family Court to seal the Court file.

Do you want OCSS to file a Motion to seal the Court file? YES _______ NO _______

If your answer is YES, you MUST complete the following statement in support of your request to protect your information in the Court file ( provide detailed information including dates, times, places and witnesses (Attach additional pages or Court orders if needed.):

AFFIDAVIT________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

I declare under penalty of perjury that the foregoing is true and correct.

Date_____________ Signature:__________________________________________________________